Education for contraceptive use by women after childbirth

This commentary is now outdated and has been replaced by a new commentary. It is included in RHL for archival purposes only. It may be cited as: Peedicayil A. Education for contraceptive use by women after childbirth: RHL commentary (last revised: 17 December 2003). The WHO Reproductive Health Library; Geneva: World Health Organization.

RHL Commentary by Peedicayil A

1. EVIDENCE SUMMARY

This review, completed in May 2001, was revised in May 2002 and assessed the effects of educating mothers postpartum about contraceptive use.

Methodologically the review is sound: the search strategy was comprehensive and well documented; only randomized and quasi-randomized trials were included; data were extracted and analysed appropriately; heterogeneity was checked for and the data were presented very well both in the text as well as in graphs. However, the lack of good quality studies limits the significance of the conclusions of the review.

Three trials from Lebanon, Nepal and Peru were included. The outcome variables were: attendance at family planning clinics and use of contraception at 40 days, nine weeks or three months post partum; and cessation of breastfeeding at three months post partum.
There was no effect on the rate of non-attendance at family planning clinics (Peto Odds Ratio (OR) 0.82, 95% Confidence Interval (CI) 0.56–1.21). Nor was there any evidence of an effect on the rate of cessation of breastfeeding at three months post partum (OR 1.00, 95% CI 0.67–1.48). There is a benefit of education on contraceptive use in the short and long term. The peto odds ratio for non-use of contraception up to 12 weeks was 0.47, 95% CI 0.39–0.58 and for non-use after 6 months was 0.52, 95% CI 0.37–0.74. However, when only the data from the good quality study conducted in Nepal were analysed, this beneficial effect was not any longer evident.

2. RELEVANCE TO UNDER-RESOURCED SETTINGS

2.1. Magnitude of the problem

Poor countries lag far behind developed nations in terms of reproductive health indicators. In India, 65 % of all women deliver in their own homes and only 48 % of married women practise contraception (1). In India the unmet need for contraception (any method) is 15 % for married women. If traditional or natural methods are excluded, the unmet need for modern contraceptives would be doubled (2).

2.2. Applicability of results

The result of this Cochrane review suggests that education about contraceptive use in the immediate postpartum period has a beneficial effect at least in the short term. The magnitude of this is unclear as the highest quality trial had a large confidence interval that included the possibility of no effect. Since the three studies included in the review were from developing countries the results would apply to resource-poor settings. However, there are likely to be local differences owing to varying literacy rates, female autonomy, access to quality health care services and cultural factors. In India, decisions regarding contraceptive use are made by the mother-in-law and other senior family members and it is difficult for a young mother to challenge or take part in decision-making (3). Higher levels of female education result in a greater likelihood that women will deliver in a health care facility and practise contraception. Education in the postpartum period may increase awareness and even desire to use contraception but the social environment must be conducive and access to contraceptive services should be easy (4).

2.3 Implementation of the intervention

Most women in South Asia breast-feed their infants. Many of these women live with their mothers and abstain from coitus for several months until they return to their own home.

The prenatal and postpartum periods are potentially good times for information and counselling about contraception. However, most often these contacts with health professionals do not include counselling on birth spacing(5). Providers can educate mothers about the Lactational Amenorrhoea Method (LAM) and advise that intrauterine devices (IUDs), condoms and other barrier methods are appropriate contraceptive methods while they are breastfeeding. In many settings efforts are concentrated on sterilization. Women tend to complete their family quickly and then get sterilized.

Most women in South Asia are not aware of birth spacing methods. What is needed is to allocate time for this important informational activity and probably organize group education in addition to one-on-one counselling. Many of these activities can be introduced without much financial burden and where these activities are already being undertaken, they will need only to be strengthened. The information provision and discussion activities need to involve also the family members of the woman so that such education is not provided in a social vacuum.

3. RESEARCH

The effect of postnatal counselling of mothers seems to be modest with the limited evidence available. There is a need for evaluating modified educational interventions with a potential effect on contraceptive use over an extended period of two or three years; also, there is a need to measure unplanned pregnancies and their termination. These modified/strengthened interventions could include education/counselling of husbands and other family members as well as evaluations of whether such education translates into women having a greater role in the decision-making process.

References

International Institute for Population Sciences (IIPS). National Family Health Survey 2000;Mumbai.

Ross JA, Winfrey WL. Unmet need for contraception in the developing world and the former Soviet union: an updated estimate. International family planning perspectives 2002;28:138-143.

Stephenson R, Tsui AO. Contextual influences in reproductive health service use in Uttar Pradesh, India. Studies in family planning 2002;33:309-320.

Ross JA, Winfrey WL. Contraceptive use, intention to use and unmet need during the extended postpartum period. International family planning perspectives 2001;27:20-27.

This document should be cited as: Peedicayil A. Education for contraceptive use by women after childbirth: RHL commentary (last revised: 17 December 2003). The WHO Reproductive Health Library; Geneva: World Health Organization.